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:: Waste Tire Su nspection Repor ion Report Number ■ <br /> State of California <br /> CIWMB 181(New 04/04) <br /> �r $ l - <br />' California Integrated Waste Management Board Survey Form - Page 1 I _-.._. 1 1 016698 <br /> Part A Y: Survey/ BLUE OR BLACK INK PEN"• y . *T"—�'ryy°r„r„ try�"'T'',i d ✓4,�7`a ✓ '�`".3' Sr;'d>�+F749aj am:��+ N �'v.„ �'+^ys � „i�+ 'fi r�'—e—y—„ �ti+r F <br /> / t� 4 ✓+. / li�a + r' ;:a' Y w 'u '� � I �nr��;i`Ni�. :..xry �i ^; r a,, r �r l <br /> L <br /> ,*��'�� � �`'u� r I d r,✓4 f :�' davr' 'l� r � ,�,Y �`��r�,��+$ i� , , ., ... ,�Y y, .� b �� .rrnh ,. <br /> Routine Type Fill one Q Re inspection, Q Referral <br /> Inspection T Q Observation <br /> TPID- �t e <br /> Site Suffix: <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date m <br /> City State ZIP Cade _ _ <br /> Time In Time Out <br /> Business Rep Title ff O AM 1 AM <br /> 0 PM 0 PM <br /> Ir / / II Y � �t <br /> Operational Status <br /> +W?�,",r�5ti"„%tem.^r�'rr�4'.'.`�'"� _'u"'d'�yt'"lt:'�9a�" ,!�I"a'e'n�;r'�u r r*pet.'„�q ro,�d,'ernA+ �,nn��Sw,PoC^r�:,'✓.N�'"& u1r�r,rl,Y',eroe;9.�^�""+r'4:",.�"� b.1�.r.cff1iii�.—�. 'r”�"�+,v"��rs,"r,f�t��,>'�r <br /> S Fp' r � Business Role <br /> Fill one only) (Fill all that app I <br /> y) G�kc4r���<,(t"caWl t��"�"vrt✓A!4 s+a,�",�`,,rr,yr�arVi,+�4tActive (D Generator <br /> O Q Closed <br /> GPS Latitude t4 <br /> Jrr7i <br /> Q Hauler ° rn <br /> LLI - L LLL O Q Inactive <br /> Longitude — QPlanned �� �� 4 Q End Use <br /> � r u�`4xfur�rw����"� `�, <br /> r;. <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder @ Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility E-NFORCEMENT STATUS <br /> V <br /> A HAULING AND MANIFEST REQUIREMENTS la lF <br /> =n „ t <br /> -- --- — Q Notice O � on Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956 Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 (a) (b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> I <br /> j Comments <br /> I <br /> I <br /> Inspection Form Included: Q' <br /> �" r / ..__ �... .. 62081 <br /> INSTRUCTIONS ON BACK Correct: incorrect: c� � <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 1. <br />